Adult

Diabetic Ketoacidosis (DKA)

FOR USE IN CRITICAL CARE RFHL NHS FT ONLY

Admission to Critical Care for Management of CONFIRMED Diabetic Ketoacidosis

- GCS < 12 - Cr > 200 - Blood ketones > 6mmol/L
- pH < 7.0 - Systolic BP < 90 mmHg - after an appropriate period of initial management

Glycaemic Control Electrolyte Supplementation Fluid Resuscitation

Target Glucose 8 - 14 mmol/l Target K+ 4.5 - 5.0 mmol/l Approximately 6000 ml in the first 24 hr

Insert Central Venous Access Use Balanced Crystalloid

(for electrolyte supplementation & monitoring) not N/Saline

0.1 unit/kg/hr Actrapid infusion Mg SO4 20mmol over 2 hr Take note of fluids given prior
(usually 6 units/hr) (aides potassium supplementation) to admission to Critical Care
and and
Patient’s usual long acting SC Fluid resuscitation should be
insulin KCl 20 - 40 mmol over 1 hr
(e.g. glargine or levemir)
(to achieve target 4.5 - 5.0 mmol/l) guided by clinical parameters

All of the following should be

Check Venous Blood Gas 1 hourly for glucose, KETONES and K+ considered when prescribing fluids
Examination findings
- patient history i.e. are they thirsty
> 14 mmol/l < 14 mmol/l - skin turgor
Repeat KCl as required - mucous membranes
(to achieve target 4.5 - 5.0 mmol/l)
Aim glucose to - peripheral skin temperature
10% dextrose
fall 3 - 5 mmol/l * Targets to aim for
per hour at 125 ml/hr and - capillary refill time < 2 sec
- heart rate < 100 bpm
- systolic blood pressure > 90 mmHg
Check Venous Blood Gas Monitor phosphate TDS - urine output > 0.5 ml/kg/hr
- if < 0.8 mmol/l Phosphate
2 - 4 hourly Polyfuser at 60ml/hr & monitor Cai
- lactate < 2 mmol/l
- ScvO2 > 65%
* No one of these targets

Target glucose is 8 - 14 mmol/l HYPOGLYCAEMIA alone means fully

resuscitated
- glc 5 - 7.9 mmol/l ž Ÿ 10% dex 25 ml/hr
GLUCOSE < 5 mmol/l
- glc > 14 mmol/l ž   10% dex 25 ml/hr
§ Reduce Actrapid to 0.5 unit/hr
§ 100ml boluses 10% dextrose
Ketones to fall by 0.5 mmol/hr § When glucose > 8 mmol/l
HCO3- to increase by 1 mmol/hr - increase 10% dextrose by 50 ml/hr
Inc. Actrapid 1 unit/hr if not improving at this rate - return Actrapid to original rate
Any hypoglycaemic episode must have a medical review

Recovery Phase
§ pH > 7.30 & HCO3 - > 18 mmol/l, Anion Gap normalised & Blood Ketones < 0.5mmol/L
§ When eating and drinking commence short acting SC insulin

- stop IV Actrapid 1 hour after 1st dose of insulin given with next meal

§ Inform Endocrine registrar (bleep 1825) for review of diabetic control

§ Inform Bed Manager (bleep 2001) of Category A transfer to Endocrine ward

Ref : The management of diabetic ketoacidosis in adults Critical Care Department, June 2016
Joint British Diabetes Societies Inpatient Care Group September 2013 Dr Nick Macartney (CD), Dr Stephen Ward (SLL), Dr Jeremy Dawson (author)